Capitol Hill Report: An Outrageous Omission

April 2, 2010

This edition of Capitol Hill Report goes into specific details about the politics that kept neurology out of the health care bill, as well as the Academy's plans for moving forward.

Congress Fails to Recognize Neurology

Since the passage of health care reform there have been a number of questions coming from Academy members about why neurology was not included in the "primary care incentive." This is the result of neurology's outrageous exclusion from the section 5501 of the Patient Protection and Affordable Care Act, the final health care reform bill. Continue reading to see how politics and process prevented the logical inclusion of a congressional incentive for the physicians who care for some of Medicare's highest need, highest cost beneficiaries.

Also known as the "primary care incentive," section 5501 provides for a 10-percent increase in reimbursement to those who bill Medicare under evaluation and management (E/M) codes at least 60 percent of the time. The Academy became aware that neurology might not be included in this section back in the summer of 2009 after the Senate Finance Committee released their first health care reform legislation draft. (I mentioned this in the July 3, 2009 edition of Capitol Hill Report).

This disappointing draft lead the Academy to push for an addition during the committee process of one word, "neurology" to this section that should more appropriately be titled the "cognitive care incentive."

In, Then Out (June 2009)

At the Academy's request, Sen. Charles Grassley (R-IA), the ranking member of the Senate Finance Committee, added the word "neurology" to the Finance Committee's draft during "bipartisan" negotiations between six of the 23 committee members. We were optimistic as I was told by Finance Committee majority staff that Democrats also supported the provision. (This was also detailed in the July 3, 2009, Capitol Hill Report)

However, the bipartisan negotiations broke down, which lead the majority staff to purposefully strip all of Sen. Grassley's provisions from the bill, including neurology. Committee Chair Max Baucus (D-MT) released a final draft of the proposal in September and sent it to the Congressional Budget Office (CBO) for a cost analysis or "score," giving the Academy no chance to add neurology before the cost analysis on the entire draft was completed. (I wrote about the CBO process in Capitol Hill Report on February 22) This draft would eventually become the basis for the final health reform bill that was signed into law March 23, 2010.

Neurology Amendment Introduced (Fall 2009)

This setback led us to recruit congressional sponsors of an amendment in both the House and Senate, as the House failed to include neurology in their health care reform proposal as well.

On the House side, Rep. Betty McCollum (D-MN) agreed to offer what became known as the Neurology Amendment". Rep. Ed Perlmutter (D-CO) pledged his support in the House Rules Committee. This was important as it is the Rules Committee that determines the "rules of debate" when a bill makes it to the House floor, including which amendments will be eligible to be offered on the floor.

In the Senate, Sen. Amy Klobuchar (D-MN) agreed to carry the Neurology Amendment, and garnered three cosponsors, including Republican Senator Susan Collins of Maine. This made neurology one of the few bipartisan amendments being offered on Capitol Hill. Sen. Grassley also introduced a separate amendment that would have included neurology. The momentum seemed to be in neurology's favor, but the political process would bring that momentum to a screeching halt.

Politics Gets in the Way (Winter/Spring 2010)

When the House health reform bill came to the Rules Committee, the committee was instructed by Speaker Nancy Pelosi (D-CA) to allow only two amendments to be debated on the House floor. The first was the Republican substitute (which failed). The second dealt with opposition to abortion funding (which passed). This left hundreds of amendments, including the neurology amendment, unconsidered.

Back in the Senate, Majority Leader Harry Reid (D-NV) and Sen. Baucus declared that before any new provision could be considered on health reform, the CBO had to provide a score and any increase in spending must be completely offset.

Knowing that obtaining a score was essential to our efforts, the Academy dedicated $15,000 to an independent firm for a cost analysis we could pass on to the CBO, with the hopes it would make their job easier.

In the meantime, we continued to send out "action alerts" from the Academy Grassroots Network, which resulted in nearly 3,000 members sending over 17,000 messages to Congress asking for their support of the Neurology Amendment and a request for a CBO score. This also became a part of our "ask" when more than 100 Academy members visited their congressional offices during Neurology on the Hill. Several members of Congress followed suit and made the request. However, in the end, the CBO never scored the amendment.

Why Didn't the CBO Score the Amendment?

After all of the requests to CBO by members of Congress, I had a conversation with the legislative director from the office of Rep. Henry Cuellar (D-TX) another supporter of the Neurology Amendment. According to Cuellar's staff, the CBO told Congressman Cuellar they simply did not have time to review any individual issues. This was a common complaint by advocacy groups across Washington. Lack of congressional resources ground the process to a halt for many issues like ours. The fact remains that from each step in the process, from committee consideration, to the floor of the US Senate, our amendment (along with hundreds of others) was prevented from moving forward in the Senate because of the lack of a score from the CBO.

Moving Forward

Members of Congress are already talking about changes that need to be made, and the Academy has begun the process of laying the groundwork to be a part of these changes.

Last month Academy Government Relations Committee and BrainPAC Executive Committee member Tom Vidic, MD, FAAN, and I met with House Ways and Means Committee (the top committee in the House) member Rep. Xavier Becerra (D-CA) and Rep. Perlmutter. Both expressed strong interest in helping us out. I also met with Rep. Charles Boustany (R-LA), who sits with Rep. Becerra on Ways and Means. He told me that Rep. Becerra has already reached out to him about the need for a "technical corrections" bill.

In the meantime, the current plan is to introduce a bill that would add neurology to the incentive, which we hope will lead to being included in the first technical corrections bill Congress addresses. Sen. Klobuchar is also requesting that MedPAC, a congressional advisory committee initially responsible for recommending the incentive to Congress, consider making a recommendation that neurology should be included. A recommendation from MedPAC would be make a very strong argument to Congress.

What is most vital at this time is your support. The American Academy of Neurology's efforts on Capitol Hill are deeply reliant on the strength of its membership. Approximately 3,000 US members responded e-mails from the Academy Grassroots Network. While it's a terrific response, it also means that 13,000 members never sent a message. If you receive and e-mail from us, take a minute to send a message, then forward that message on to your fellow Academy members.

In the end this outrageous exclusion will not stand as the future of access to care for patients with neurologic conditions remains at risk. This will remain at the top of the Academy's federal priorities and we will not fail for lack of effort.